Final Report > Chapter 21: Introduction > Phase Two of the Inquiry

Phase Two of the Inquiry

6 Phase One focused on the evidence of what happened in Bristol. It served to identify problems that need to be addressed. After hearing the Bristol evidence, we turned to Phase Two of the Inquiry. In response to the requirement in the Inquiry's Terms of Reference to make recommendations to `help to secure high quality care across the NHS', we asked questions as to what was currently working well within the NHS and what was working less well and why. We decided to seek an answer to the deceptively simple problem: what are the determining factors which enable a large complex organisation to meet its objectives? We sought ideas, submissions and argument on seven topics from over 150 experts and more than 50 organisations. We chose the seven topics because the evidence we heard during Phase One suggested that they were of central relevance to the quality of healthcare. The seminar topics were as follows:

• what factors influence an organisation's performance, and what factors influence the performance of the NHS;
• the culture of the NHS;
• leadership;
• people: education, training, development and regulation of professionals;
• systems: safety, risk and information;
• empowering the public and patients; and
• children and children's healthcare services.

7 On each topic, the Inquiry's Panel sought written submissions from a wide range of interested organisations and subsequently held a seminar, in public, with 20 or so invited participants. All of the written contributions, plus an account of each seminar, were published on the Inquiry's website during the course of spring and summer 2000. [5] We heard from people working within or close to the NHS, as well as from those who hold senior positions in entirely different walks of life, elsewhere in the public sector, and in the private sector. Other large organisations, both public and private, face challenges similar to those confronted by the NHS, in terms of pursuing quality and safety, leading and managing a workforce of professionals, working within tight financial constraints, while subject to a variety of regulatory frameworks. We were struck by how frequently it was asserted in the Inquiry's seminars that the NHS is unique and yet how often, on examination, the similarities to other organisations became apparent.

8 To illustrate the point, there are many other organisations which employ professionally qualified people who give a service direct to the public. We heard from schools and local authorities, and from law and accountancy firms. Other industries face issues of quality and safety, not least the nuclear, chemical and airline industries. We invited contributions from participants from these sectors also. On the issue of safety, we were very struck by the way in which the airline industry has been active over the years in improving safety. By way of illustration, in a recent pilot study, Professor Charles Vincent and colleagues wrote that: `Although we cannot extrapolate with any precision, our findings strongly suggest that adverse events are a serious problem in the NHS, as they are in the United States and Australia. We estimate that around 5% of the 8.5 million patients admitted to hospitals in England and Wales each year experience preventable [our emphasis] adverse events ...' [6] Professor Vincent was not able to say, at this stage, what proportion of these preventable adverse events result in death. Studies in the USA suggest that the numbers are high. Estimates vary, but it is said that between 44,000 and 98,000 Americans die in hospitals each year as a result of preventable medical errors, some of which are due to accidents, others to negligence. [7] If the rate were similar in the UK, then as many as 25,000 people could be dying each year from preventable adverse events. Whether the result of accident or negligence, all are, by definition, avoidable. This scale of human loss is the equivalent of the avoidable crashing of one jumbo jet a week. If air travel were so unsafe, it is unlikely that airlines would survive more than two or three weeks. Something would be done. Of course, air travel is an extremely safe form of transport. Systems and procedures have been put in place to ensure this. The question which demands an answer is why, in the face of the evidence of avoidable deaths (and ignoring for the moment the undoubtedly larger incidence of avoidable injury), this is not so in the case of the NHS. One of the challenges for the future becomes, therefore, what can the NHS learn from other large organisations which have confronted and addressed issues such as safety which are of major concern to the NHS.

Footnotes

[5] See Annex B for a summary report of each seminar. See Inquiry website www.bristol-inquiry.org.uk for the discussion points and the position papers submitted by individuals and by organisations to each seminar

[6] Vincent C, Neale G, Woloshynowch M. `Adverse events in British hospitals: preliminary retrospective overview.' `BMJ' 2001; 322: 517 - 519. www.bmj.com Professor Vincent defines an adverse event as: `... unintended injuries caused by medical management rather than the disease process'

[7] Kohn L. et al., eds. `To Err is Human: Building a Safer Health System', Washington DC: National Academy Press, 1999; p. 26 gives details of two studies, one in New York state and the other in the states of Utah and Colorado, where the percentages of adverse events resulting in death were, respectively, 13.6% and 8.8%